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91Acute Care
1. C Extinction is the result of parietal lobe damage and is characterized by the inability to discern stimulation on the side contralateral to the infarct when stimulated on both sides simultaneously. With extinction, sensation is intact when each side is individually stimulated—only lost with double, or multiple, stimuli simultaneously. Neuropathy is a condition of peripheral nerves, usually in the lower extremities, characterized by numbness, tingling, and pain. Paresthesia is also a peripheral nerve condition characterized by numbness, tingling, and a pins-and-needles sensation.
2. A Hunt and Hess, Fisher scale, and WFNS scores are all used in SAH patients, but Hunt and Hess is based on what symptoms are present, and Fisher is based on the amount of blood present, while the WFNS is based on the Glasgow Coma Scale score and presence or absence of motor deficit (Morrison, 2014).
3. C The ABCD2 score predicts short-term risk of stroke in patients with TIA. The acronym stands for age, blood pressure, clinical features, duration of symptoms, and diabetes (Morrison, 2014).
4. 92D Classic in brainstem strokes, the four Ds are dysphagia, dysarthria, diplopia, and dysmetria, and crossed signs indicate that motor and sensory deficits do not match the classic pattern seen in hemispheric strokes.
5. D Homonymous hemianopia is the loss of half of the field of view on the same side in both eyes. It is also referred to as a homonymous hemianopsia. It occurs because of the way part of the optic nerve fibers from each eye crossover as they pass to the back of the brain. The visual images that we see on the right side travel from both eyes to the left side of the brain, while the visual images we see on the left side in each eye travels to the right side of the brain. Therefore, damage to the right side of the posterior portion of the brain can cause a loss of the left field of view in both eyes. Likewise, damage to the left posterior brain can cause a loss of the right field of vision (Windsor & Windsor, 2004).
6. C The Glasgow Coma Scale was developed in 1974 to evaluate the depth of decreased consciousness and coma in the head injury population. The range of score is 0 to 15, with points deducted for deficit, so the higher the score, the better the patient status. The motor component only tests for best effort, so a stroke patient with hemiparesis could still get a normal motor score owing to being able to demonstrate motor strength with the unaffected limb. Therefore it does not have high reliability with the stroke population.
7. B CN VII, the facial nerve, is involved in smiling and raising eyebrows; CN III, the oculomotor nerve, is involved in eye movements; CN I, the olfactory nerve, is involved in smell; and CN XII, the hypoglossal nerve, is involved in tongue movement.
8. A CN III, the oculomotor nerve, is involved in eye movements; CN II, the optic nerve, is involved in vision or visual confrontation; CN VI, the Abducens nerve, is involved in lateral vision; and CN IV, the Trochlear nerve, is involved in looking down toward the floor.
9. B The rules for scoring ataxia in the NIHSS state that you should only score an inability as ataxia if the inability to perform the task is out of proportion to the patient’s weakness. Since this patient scored a 4 for motor ability on the left leg, the patient has no movement at all. This patient’s inability to do the ataxia exam is due to weakness, not to inability to coordinate the movement, so does not get an ataxia score.
10. 93D Research evidence has proven the admission NIHSS to be a reliable predictor of discharge disposition based on the ranges described in the question.
11. A The mRS is a commonly used scale for measuring the degree of disability or dependence in the daily activities of the stroke population. The scores range from 0 to 6, with 0 being no deficits, and 6 being dead. A score of 1 is defined as no significant disability, able to carry out all usual activities, despite some symptoms. A score of 2 to 5 indicates varying degrees of dependence.
12. B The Barthel Index is used to measure performance in specific activities of daily living (ADL). The 10 areas are scored 1 to 10, with a total score possible of 100. The higher the score, the more likely the patient is to be independent. It is not a required daily score for stroke-certified centers, and it is not as highly correlated with hemorrhagic stroke as with ischemic stroke. It is not synonymous with FIM, which is Functional Independence Measure, a scale used in the postacute rehabilitation setting.
13. D Decerebrate posturing is characterized by a rigid, possibly arched, spine, rigidly extended arms and legs, and plantar flexion. It is seen in the stroke population in patients with increased intracranial pressure to the point of pressure on the brainstem, or herniation. Headache, increased blood pressure, and pupil changes occur earlier in the setting of acute stroke.
1. B, C, D Hydrocephalus develops when the blood clots over the arachnoid villi, blocking flow of cerebrospinal fluid; vasospasm develops because the blood is irritating the outer layer of the arteries causing them to spasm; and seizure activity is the result of the irritation of the blood on the surrounding tissue—think of it as a short circuit of the brain’s electrical system.
2. A Endovascular embolization is done via an arterial approach, not transcranial, so groin checks would be done along with the every 15 minutes vitals and neurologic checks.
3. C Straining involves the Valsalva maneuver, which results in transient high blood pressure. For patients with new stroke, and possibly 94inactive autoregulation, blood pressure spikes could be dangerous. Autoregulation is present in normal, healthy brains. It is the mechanism that keeps a steady intracerebral pressure, regardless of what is going on in the body. When the brain is injured, autoregulation may be temporarily inactivated, so the brain is particularly susceptible to highs and lows of systemic blood pressure.
4. D Hypoxia could result from all three: aspiration pneumonia because the inflammatory process produces excess mucus and secretions that inhibit oxygen absorption and exchange; hypoventilation because inadequate inflation or low respiratory rate limits the amount of oxygen exchanged; and airway obstruction because if oxygenated air cannot get into the lungs, it cannot get absorbed into the blood.
5. A If your restless patient is unable to communicate what is wrong, assessment of possible causes of distress, respiratory or pain, will help to determine the appropriate treatment. Just increasing the dose of sedative is dangerous because if the cause of the restlessness is found and resolved, there is risk of oversedation and hypotension, which is not good for the patient’s injured brain.
6. B Research has shown that sustained hyperglycemia after stroke is associated with worse outcomes, even in patients without diabetes.
7. C Fever results in cerebral edema owing to the breakdown of the blood–brain barrier.
8. B Shivering is a common challenge with surface cooling, and if not controlled can raise the body temperature negating the impact of the cooling therapy.
9. D Even though you were told in the report that the patient passed a swallow screen, if it is not documented the most prudent thing is to simply repeat it, as it is not a difficult process. For a patient with a change in neurologic status or an NIHSS increase of 4 points or more, you should anticipate that the ability to swallow safely may also have changed; and for a patient who had been deemed safe to swallow but is drooling, repeating the swallow screen is essential, as new drooling is closely linked to swallow ability.
10. 95A Petechial hemorrhage is defined as patchy hemorrhage, and patients are usually asymptomatic; parenchymal hemorrhage is defined as hemorrhage with mass effect, and patients are usually symptomatic (Morrison, 2014, p. 125).
11. D CSW and SIADH are not synonymous; CSW is caused by excessive removal of salt by the kidneys and is treated with sodium replacement; SIADH is dilutional low sodium and is treated with fluid restriction (Morrison, 2014, p. 124).
12. C The blood pressure parameters for ischemic and hemorrhagic patients are not the same, with hemorrhagic patients having a lower range of acceptable blood pressure than ischemic patients.
13. B Reperfusion syndrome is described as the inflammatory reaction to the restoration of blood flow to an ischemic area with common symptoms being ipsilateral headache and contralateral neurologic deficits. It is associated with postprocedure hypertension and treatment is tight management of the blood pressure. It is not a second stroke event, although without good medical management, that could occur. It also would not result from an aneurysm embolization as that does not result in restored circulation to an ischemic area.
14. C The external landmark for leveling an EVD is the tragus of the ear; the internal landmark is the foramen of Monroe.
15. B Even though the patient does not appear to be in respiratory distress, the injured brain needs better oxygenation than an 88% saturation provides, so notify the provider if that is what it is on recheck.
16. B The best response in this situation is to make sure the health care team is aware, and that there is a family meeting in which as many members of the team as possible participate.
17. B Most deaths from large MCA infarcts occur in the first week but usually not during the first day. At that time, the infarct may still be evolving. The cause of death is cerebral edema, which is not yet full blown on the first day.
18. C Right parietal lobe infarcts are associated with impulsivity and extinction, or neglect of the left side. Cerebellar strokes are associated with lack 96of coordination (ataxia) and imbalance; basal ganglia strokes are associated with lacunar strokes that are pure sensory or pure motor; temporal lobe strokes are associated with receptive language problems and memory deficit.
1. C The risk of vasospasm is highest in the first 10 days after SAH; the risk of rebleed is highest in the first 24 hours after SAH. If the patient had been on anticoagulation therapy and was having it resumed, it would been restarted safely earlier than Day 7, so an additional 3 to 4 days as stated by the doctor would not make sense.
2. D Patients with hemiparesis of the upper extremity can experience arm pain as a result of poor technique used by staff when repositioning or mobilizing them. It can also result from the weight of the arm pulling down if unsupported. The best next action would be to reposition and ensure that the arm is properly supported and assess for possible relief of pain.
3. C Most dysphagia screens are simple to do, so the best action would be to go ahead and do a brief screen so that the patient can receive the pain medication as quickly and safely as possible.
4. A Hemoglobin A1C is an indicator of the average level of blood sugar over the past 2 to 3 months. A level greater than 6.5% meets the threshold for diagnosis of diabetes; a fasting blood sugar greater than 126 also meets the threshold.
5. D Paging the SLP stat would be best to ensure the patient receives the appropriate evaluation as soon as possible. As you had just performed the swallow screen shortly before rounds, there is no need to repeat it, but there is actually no harm either, so answer A would be okay.
6. B Postural hypotension is defined as occurring within 5 minutes of standing from supine. The term has become more broadly used for patients whose BP drops as a result of sitting for an extended period, but it is technically not postural hypotension (Arbique, Cheek, Welliver, & Vongpatanasin, 2014).
7. 97B With TED stockings, the benefit does not outweigh the risk of harm. In the acute population, there is a high likelihood of the stockings being applied by someone other than the patient, and with possible language or sensory deficits, the patient cannot always communicate, or be aware, if there is poor fit and compromised circulation or skin integrity (Dennis et al., 2009).
8. D Anticoagulation during the acute phase of stroke recovery is most risky in ICH, unsecured aneurysms, and large territory ischemic stroke patients.
9. B Facilitation of regular bladder emptying limits the risk of UTI because of less retention time.
10. A Patients with neurologic injury, such as stroke, are at risk for incontinence and retention. Retention of urine in the bladder is a risk for UTI.
11. C Stroke patients with hemiparesis have limited ability to reposition themselves; stroke patients with sensory deficit are not aware of the warning signs of pain that most people feel when pressure points are developing (Alexander, 2013).
12. B A patient with a right-sided infarct who experiences neglect will not be aware of the left side, so initial approach, and the bedside table, should be on the right side.
13. C Cryptogenic stroke is defined as a stroke that has no definite cause, all known causes have been ruled out. Cryptic means mysterious, so it makes sense that cryptogenic means without known cause.
14. A Aphasia is a term that refers to many types of language dysfunction, and inaccurate naming is one of them. Slurred speech would be dysarthria; inability to initiate would be apraxia; refusal to speak would be stubbornness.
15. B Recanalization is defined as restoration of a lumen in a blood vessel following thrombotic occlusion, or reopening of a blocked vessel.
16. D Evidence has shown that early antithrombotic administration leads to better patient outcomes. Stroke performance measure 5 (STK 5) requires the antithrombotic to be administered by end of Day 2 (midnight). What 98makes this case challenging is that the patient got tPA, and you cannot administer it for 24 hours post tPA (so not before 9:00 p.m.), leaving only a few hours to give it within the best practice parameters.
17. C The system for determining the levels and classes of evidence in making clinical care decisions was developed in 1979 through a collaborative process among physicians, scientists, and researchers. “Level” refers to the estimate of certainty based on size of population studied, and “class” refers to the estimate of benefit versus risk; there are four classes, and three levels utilized, and a Class I, Level A is the highest level of recommendation. The table showing all the levels and classes can be found in most of the American Heart Association/American Stroke Association Guidelines (Burns, Rohrich, & Chung, 2011).
18. A Some stroke patients (usually younger patients with large territory strokes) have a hemicraniectomy performed to allow for brain swelling and to prevent herniation or secondary stroke from compression. Without the bone flap (piece of bone), they are at risk of brain injury so they wear a helmet at all times, except for during daily hygiene.
19. D A DNR order simply means that if the patient were to experience cardiac or respiratory arrest, there would be no cardiopulmonary resuscitation (CPR) or intubation. It does not mean that care stops or changes in any other way.
20. B Coughing is a sign of possible swallowing difficulty, and the patient should be rescreened right away, so that no more medications or food are given without determination of swallowing ability. You will also monitor temperature and breath sounds, but the most important thing to do right away is to rescreen.
21. C While patients have a right to make treatment decisions, that is only after they have received the proper education and information. Make sure the patient understands the consequence of an untreated atrial fibrillation, which is another stroke.
22. A Factor V Leiden is a mutation of one of the clotting factors in the blood called Factor V, which can increase the chance of developing blood clots (thrombophilia).
23. 99B TIAs are a classic warning sign that a stroke might occur in the future; TIA is to stroke like angina is to myocardial infarction. Patients who understand this would know that if they have symptoms again, they will call 911.
24. C An INR of 2.5 is within therapeutic range for most anticoagulated patients, 2.5 to 3.5.
25. A Evidence has shown that patients who arrive via emergency medical services (EMS) have faster access to identification and treatment of their stroke, so the son stating that he would take her to the emergency department (ED) indicates the need for more education about the importance of calling 911.
26. A The only correct answer is the importance of keeping follow-up appointments; B is incorrect because it says high-sodium diet, which is just the opposite of what is correct.
27. B It is important to control expectations, and carotid endarterectomy is a prevention measure—it will not change the fact that the patient has had a stroke resulting in vision change. The patient may be getting vision therapy, but it is not correct to say that it will restore the vision, as there are no guarantees that this will happen.
28. C MCA territory strokes usually involve sizable brain tissue being affected, which usually is accompanied by cerebral edema. On Day 3, the patient will likely still be groggy, and should not be left alone to feed himself or herself.
29. A A multicenter study comparing aspirin and warfarin for treatment of stroke patients with PFO found no difference in stroke risk between treatment groups but found a significantly higher rate of hemorrhage in the warfarin-treated group. PFO closure would not be recommended in a patient with a first stroke who has not yet been treated with an antithrombotic medication.
References
Alexander, S. (Ed.). (2013). Evidence-based nursing care for stroke and neurovascular conditions. Ames, IA: Wiley-Blackwell.
100Arbique, D., Cheek, D., Welliver, M., & Vongpatanasin, W. (2014). Management of neurogenic orthostatic hypotension. Journal of the American Medical Directors Association, 15(4), 234–239.
Burns, P. B., Rohrich, R. J., & Chung, K. C. (2011). The levels of evidence and their role in evidence-based medicine. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3124652
Dennis, M., Sandercock, P. A. G., Reid, J., Graham, C., Murray, G., Venables, G., . . . Bowler, G. (2009). Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS trial 1): A multicentre, randomised controlled trial. The Lancet, 373(9679), 1958–1965.
Morrison, K. J. (2014). Fast facts for stroke care nursing: An expert guide in a nutshell. New York, NY: Springer Publishing.
Windsor, L., & Windsor, R. (2004). Hemianopsia (hemianopia). Retrieved from http://www.hemianopsia.net